Government dysfunction: It's enough to make a grown man cry

“If the 113th Congress was a sports team, it would be on a record-breaking streak of
futility,” reported the Brookings Institution earlier this year.

The institution's analysis found that fewer than 1% of the bills introduced in the
current session had become law, the worst record since the “Do Nothing”
Congress that Harry S Truman campaigned against in 1947.

This dysfunction is due mainly to the fact that Congress is more polarized now than
ever, according to the National Journal, and it isn't going to get better. In February, the Journal cited an observation by Gary Jacobson, a political scientist at University of California,
San Diego, that “There's nothing that will break this [trend]. Voters have
been voting along party lines at the highest rate in 50 years; they expressed that
vote at the congressional and presidential levels. It's hard for members to win in
districts where their party is not favored.”

The evidence of government dysfunction can be found not just in the lack of lawmaking
by lawmakers. It can be found in the historic decision by the Republican-controlled
House of Representatives to sue a sitting Democratic president for abuse of power
because he delayed implementation of the Affordable Care Act's (ACA) employer mandate—a
law, and a mandate, that Republicans themselves oppose.

It can be found in an administration that its critics say is stretching the boundaries
of executive decision making, the reason why House Republicans say they have no choice
but to sue the president. The administration's rejoinder is that the president has
no choice but to take executive actions because Congress isn't doing its job. “If
Congress won't act, then I will,” President Obama has said on numerous occasions.

Dysfunction can be found not just in Washington, but in state capitals as well. Take
Virginia, which is locked in a battle between a Democratic governor and a Republican-controlled
House of Delegates over Medicaid expansion. The governor, and the state Senate, favor
it, while the House of Delegates has steadfastly refused to consider it. (Virginia
is not alone. About half the states have refused to go along with the ACA's Medicaid
expansion, collectively leaving millions of poor people without health insurance,
despite the fact that the federal government will pay for more than 90% of the cost.)

Is it little wonder that opinion polls find that the public's trust in government
is at an all-time low? Or that Congress is less popular than cockroaches or traffic
jams?

It would be funny, except it is not. The country is paying a huge price because our
government has become dysfunctional. Consider just the following issues that are important
to ACP.

The ACA: ACP supports the overall goals of the ACA and believes that the evidence shows it
has been largely successful in driving down the number of uninsured. However, there
is a lot about the law that might be improved, aspects that in a less ideological
era Republicans and Democrats alike could agree on (for example, policies to expand
the primary care workforce). But because the only option that most Republicans will
accept is complete repeal, and the president and Democrats say repeal is not an option,
nothing gets done.

The Sustainable Growth Rate (SGR) formula: Because Republicans and Democrats can't agree on how to pay for repealing the Medicare
SGR formula (even though—surprise, surprise—they actually had been making
bipartisan progress on what they wanted to replace it with), we are again stuck with
another short-term patch, which expires on April 1, 2015.

Medicaid primary care pay parity: This program, which was created and funded by the ACA, pays internal medicine specialists
and other primary care physicians no less than the Medicare rates for visits and immunizations
provided to Medicaid enrollees. The problem is that it expires at the end of this
year, and unless Congress can find a bipartisan way to continue it, physicians in
most states will face deep payment cuts on Jan. 1, 2015.

Firearms injury prevention: Polls show the overwhelming majority of Americans support background checks to keep
guns out of the hands of people who are likely to harm themselves or others, yet legislation
to close loopholes in the current background check system is dead in Congress, because
of fierce opposition by the National Rifle Association and other ideologues who view
any restrictions, no matter how modest, as an unacceptable government intrusion.

Deficit reduction and entitlement reform: Remember when there was talk about a “grand bargain” to reduce the deficit
by reforming Medicare and other entitlement programs while raising taxes on the well-off?
Well, it never got beyond talk, because of conservative opposition to any tax increases
and liberal opposition to any reductions in entitlement benefits.

Both political parties, of course, acknowledge that the country is gridlocked. But
they blame each other for it. The truth is that the fault really lies with us, the voters. If we keep on electing ideologues who won't compromise, we will continue
to get ideologically divided federal and state governments that are unable to compromise
for the common good. If we keep on re-electing members of Congress who can't get anything
done, then we will continue to get a Congress that doesn't get anything done.

As Mick Jagger of the Rolling Stones sang, it's enough to make a grown man cry.

Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. ACP Internist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.